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Heart rate-lowering calcium antagonists in hypertensive post-myocardial infarction patients
F H Messerli1, J F Hansen, R S Gibson
1Department of Internal Medicine, Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, Louisiana, USA. fmesserli@aol.com
Insights
Heart rate-lowering calcium antagonists reduce event rates in hypertensive patients post-myocardial infarction. However, these drugs are only beneficial for patients without pulmonary congestion, as those with congestion experienced increased mortality.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Hypertension and post-myocardial infarction (MI) are significant risk factors for cardiovascular events.
- Calcium antagonists are a class of drugs that can lower heart rate and blood pressure.
Purpose of the Study:
- To analyze the effects of heart rate-lowering calcium antagonists in hypertensive patients who have experienced a myocardial infarction.
- To assess the impact of these drugs on mortality and event rates in this patient population.
Main Methods:
- Pooled data from three large, randomized, placebo-controlled secondary prevention trials (Danish Verapamil Infarction Trials, Multicentre Diltiazem Post-Infarction Trial).
- Inclusion of 1,325 hypertensive post-MI patients, with 667 receiving drug therapy and 658 receiving placebo.
- Blinded therapy assessment for mortality and event rates.
Main Results:
- Heart rate-lowering calcium antagonists significantly reduced event rates (21.4% vs. 27.4%, RR=0.76, P=0.013).
- Overall mortality reduction was not statistically significant (15.1% vs. 17.5%, RR=0.87, P=0.296).
- In patients without pulmonary congestion, mortality showed a trend towards reduction (11.3% vs. 15.3%, RR=0.72, P=0.066) and event rates were significantly reduced (18% vs. 24.4%, RR=0.70, P=0.011).
- In patients with pulmonary congestion, calcium antagonists were associated with a 25% increase in mortality (RR=1.25, P=0.339).
Conclusions:
- Heart rate-lowering calcium antagonists effectively decrease event rates in hypertensive post-MI patients.
- The benefit is limited to patients without pulmonary congestion; those with pulmonary congestion may experience increased mortality.
Objectives:
To analyse effects of a heart rate-lowering calcium antagonist in hypertensive post-myocardial infarction patients.
Design And Methods:
From three large, randomized, placebo-controlled, secondary prevention trials investigating verapamil or diltiazem (the first and second Danish Verapamil Infarction Trials and the Multicentre Diltiazem Post-Infarction Trial) data from a total of 1,325 hypertensive post-myocardial infarction patients (drugs = 667, placebo = 658) were pooled to assess effect of blinded therapy on mortality and event rates.
Results:
Treatment with heart rate-lowering calcium antagonists was associated with significant reduction in event rates [21.4 versus 27.4%; risk ratio (RR) = 0.76, confidence interval (CI) = 0.61 -0.95, P= 0.013]. Mortality rates in the treatment group were 15.1 versus 17.5% in the control group (RR = 0.87, CI = 0.66-1.13, P= 0.296). Among the subset of 964 hypertensive patients without pulmonary congestion, there was some reduction in mortality rate (11.3 versus 15.3% in the control group; RR = 0.72, P= 0.066) and significant reduction in event rates (18 versus 24.4% for control group; RR = 0.70, P= 0.011). In patients with pulmonary congestion and hypertension, however, calcium antagonists were associated with a 25% increase in mortality (RR = 1.25, P= 0.339), while event rate RR was 1.00. After an adjustment for significant covariates, RR for mortality in treatment versus control groups was 0.76 (P= 0.159). For event rates, RR was 0.74 (P= 0.057).
Conclusions:
Heart rate-lowering calcium antagonists decrease event rates in hypertensive post-myocardial infarction patients, but only in those without pulmonary congestion.